New York Times New Priority: Saving Feet of Diabetics By BARNABY J. FEDER Published: August 30, 2005 "William Buchanan knew that his diabetes could lead to foot and ankle ulcers, and that the consequences could be dire. His mother also had diabetes, and he had watched her foot wounds fester to the point that her right leg was amputated. Mr. Buchanan, a 74-year-old resident of Queens, watched his own feet and fretted. "I didn't know there was anything I could do about it," he said. That changed last month when HIP, the health care provider that administers his Medicare plan, enrolled him in a new diabetes management program that makes him a partner in protecting his feet. HIP is aggressively screening 6,500 diabetic clients like Mr. Buchanan who are at high risk for developing foot wounds. It is putting many of them into new orthotic shoes that they are actually likely to wear, unlike the older lace-up pair that Mr. Buchanan, who is obese, had trouble putting on. And it is sending them home with a new $150 device that makes it easy to check the skin temperature on the bottom of their feet every day, along with instructions to phone immediately if either foot is warmer than 90 degrees or if one foot is 4 degrees warmer than the other. Either reading is an early warning sign that an ulcer is developing. HIP, based in New York, intends to dispel longstanding assumptions about the pressure wounds to ankles and feet that are among the most debilitating symptoms of diabetes. Such injuries, which frequently force the patients into premature retirement and restrict their mobility, often become infected. The next step for roughly 50,000 Americans each year is the amputation of a leg or foot. After that, many people fall into an accelerated decline, 70 percent dying within five years, according to data published by the National Institutes of Health. Patients with lung cancer are part of the only major disease group with significantly worse survival rates, according to government statistics. Doctors have traditionally viewed amputation as inevitable for many diabetics with foot wounds, a group that includes about 25 percent of all people with diabetes and more than half of diabetics who are old enough to qualify for Medicare. But research suggests that anywhere from 50 percent to 85 percent of diabetic foot amputations are preventable. "We see amputation as a failure, not the expected outcome," said Dr. Barry H. Kohn, medical director for care management at HIP. Part of the equation is a rapidly expanding array of drugs, bioengineered skin replacements and devices and surgical procedures to fight infection and stimulate wound healing. But this technology can cost tens or even hundreds of thousands of dollars. As a result, interest is growing in simple procedures and tools, like those that HIP has begun providing, which can warn people with diabetes when they are at risk of developing a wound and, in most cases, help them prevent it. "The foot is the most common reason for hospitalization of diabetics, and the most preventable," said Dr. David G. Armstrong, professor of surgery and chairman of research at the Dr. William M. Scholl College of Podiatric Medicine in North Chicago, Ill. The research on preventing foot wounds grew out of frustration, said Dr. Jeffrey L. Tredwell, a former podiatric surgeon who was among a group of health care providers who founded XLHealth, a Baltimore-based disease management company that is running the diabetes program for HIP. "All we did was wait for a wound and treat it," said Dr. Tredwell, recalling his years as a surgeon. "It was a good living but not very gratifying." In fact, it was downright depressing. Dr. Tredwell and other podiatric surgeons could see that many of the injuries never healed and that new wounds seemed to strike the patients as fast as the older ones could be treated. The number of victims was growing each year, tracking the nation's obesity epidemic, because the same eating habits that pile on weight are often implicated in the onset of diabetes. Dr. Tredwell had little data to go on when he first grew concerned. But research since then has shown that half or more of diabetic foot sores become infected and 20 percent of those infections lead to amputations. Amputation puts more stress on the heart, which is thought to be the main reason diabetics undergoing it run elevated risks of dying within a few years. Dr. Tredwell and like-minded podiatrists took inspiration from Dr. Paul Brand, whose pioneering research on leprosy in India during the 1940's spotlighted the value of wound prevention in treating that disease. Dr. Brand recognized that the decay of hands and feet associated with leprosy stemmed from the victims' loss of a sensation of pain in their limbs. That left them vulnerable to wounding themselves without realizing it and put them at high risk of developing serious infections. Diabetics suffer a similar loss of sensation, called neuropathy, in their feet. In patients where it is identified, doctors often discover a wide range of other diabetic problems that are developing silently. A high percentage of victims of foot neuropathy also suffer from the early stages of peripheral vascular disease, a narrowing of the arteries that carry blood to the feet. Once vascular disease has progressed to the point that it restricts blood flow to a wound site, the chances the wound will heal drop sharply. Moreover, nearly every diabetes patient with the foot complications has begun to develop heart disease and other upper body ailments associated with diabetes. "There's almost a one-to-one relationship between diabetic foot problems and heart disease," said Dr. Tredwell. Dr. Tredwell and the other founders of XLHealth, which was originally named Diabetex, concluded that early detection of foot neuropathy and vascular diseases might lead to treatment that could head off amputations. They also said patients might be placed earlier on the proper drugs to manage heart disease and to maintain the health of other organs like the kidneys and eyes that are damaged by diabetes. XLHealth and HIP negotiated for almost three years before reaching their disease management agreement. They declined to disclose the terms, but HIP is expecting to break even in the first year and to save money after that, as fewer patients require hospitalization. In addition, better foot health is expected to allow the diabetic patients to lead more active lives. Whether the savings are actually achieved may affect how fast other providers embrace more aggressive prevention of diabetic foot ailments. As things stand now, the National Committee for Quality Assurance, the nonprofit group that sets guidelines for employers to use in comparing health plans, does not factor the availability of this kind of program into its ratings."